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Slipped Capital Femoral Epiphysis

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Other Names

  • SCFE

Background

  • This page refers to Slipped Capital Femoral Epiphysis (SCFE), a pathologic process seen in skeletally immature individuals where the epiphysis is noted to slip off the metaphysis

History

  • Originally described by Ambrose Pare in 1572 [1]

Epidemiology

  • Manifests at the average ages of 13.5 (boys) and 12 (girls)
  • Boys constitute 60% of cases
  • Typically occurs in overweight and obese adolescents
  • Half of adolescents with SCFE at are the 95th percentile of weight for their age [2]
  • Various racial frequencies
  • 1.0 for Caucasians
  • 2.5 for Hispanics
  • 3.9 for African Americans
  • 5.6 for Polynesians
  • Incidence is 0.33 /100,000 to 24.58/ 100,000 children aged 8-15 years old [3]

Pathophysiology

General

  • The capital femoral epiphysis becomes displaced from the metaphysis
  • This occurs through the epiphyseal plate
  • The slip can be varus (medial and posterior epiphyseal displacement) or valgus (lateral and superior displacement)
  • 18-50% of children experience bilateral SCFE
  • 50-60% of children who experience bilateral SCFE are afflicted simultaneously on each side
  • The children who present with unilateral involvement experience a contralateral SCFE within 18 months [3]
  • Due to a combination of both mechanical and metabolic factors
  • Mechanical factors
  • The physis experiences an abnormally high load due to obesity
  • Femoral retroversion and increased physeal obliquity also predisposes the physis to slippage
  • Metabolic Factors
  • Physis itself is abnormally weak, potentially due to
  • Endocrine disorders
  • Dysregulation of chondrocytes in hypertrophic layer of physis[4]

Associated Conditions

  • Endocrine Disorders
  • Renal Failure Osteodystrophy
  • Radiation Therapy [2]

Risk Factors

  • Adolescent Obesity [2]

Differential Diagnosis

Clinical Features

  • History
  • Patients complain of pain poorly localized to the groin, thigh, or knee
  • Patients may limp
  • Physical Exam
  • Decreased Range of motion of the hip, especially internal rotation
  • Obligatory external rotation when hip is flexed to 90 degrees
  • Patients with stable SCFE are able to bear weight on affected hip
  • Patients with unstable SCFE are unable to bear weight on affected hip [6].

Evaluation

Radiographs

  • Need to obtain an anteroposterior view and frog-leg lateral view of the pelvis
  • Findings seen on anteroposterior radiograph
  • Steel Sign: a double density that is localized to the metaphysis, due to the epiphysis slipping and becoming superimposed on the metaphysis
  • Klein’s line: A line drawn from the superior aspect of the femoral neck should intersect with the epiphysis
  • In a patient with SCFE, the epiphysis is below this line
  • A widended growth plate compared to the contralateral side
  • Shortened epiphyseal height compared to the contralateral side
  • A prominent lesser trochanter compared to the contralateral side, due to external rotation of the femur
  • Frog leg radiograph can be used to classify the severity of SCFE as either mild, moderate, or severe [5]

Classification

  • SCFE can be classified by three ways
  • Severity of the slip based on measurement of displacement
  • Patient's ability to walk
  • Pre-slip, Acute SCFE, Chronic SCFE, Acute-On-Chronic SCFE

Severity of Slip

  • Frog leg radiograph can classify the severity of the slip
Classification Description
Mild The epiphysis is displaced less than one third the width of the metaphysis
Moderate The epiphysis is displaced between one-third and one-half the width of the metaphysis
Severe The epiphysis is displaced greater than one-half the width of the metaphysis[2]

Ambulatory Status

Classification Description
Stable SCFE
  • Patient has the ability to walk with external rotation of the foot
  • Patient may have a mild limp
  • Internal rotation of the hip is limited
Unstable SCFE
  • The patient is unable to walk due to severe pain
  • When hip is flexed to 90 degrees, there is obligatory external rotation of the hip
  • 10-35% of patients fall into this category [7]

History and Physical Exam Findings

Classification Description
Pre-slip
  • Patient has weakness in lower extremity
  • Patient may report limping
  • Pain with exertion in the groin, knee, thigh
  • Decreased internal rotation of hip, and guarding present on physical exam
Acute SCFE
  • Displacement has occured through the physis
  • Symptoms present for less than three weeks
  • 10-15% of patients fall into this category
  • Physical exam shows external rotational deformity of the lower extremity
  • Hip motion limited due to pain
  • Patients may report a 1-3 month history of hip, thigh, knee pain or a limp before the actual displacement
  • Weight bearing elicits pain
Chronic SCFE
  • 85% of patients fall into this category
  • Patients report pain in groin, thigh, knee
  • Patients walk with limp
  • Symptoms last greater than three weeks, typically last several months to years
  • Physical exam shows antalgic gait, with no hip internal rotation, abduction, or flexion
  • When patient lies supine with affected hip flexed, the lower extremity will spontaneously abduct and externally rotate
Acute-On-Chronic SCFE
  • A patient with chronic SCFE develops sudden onset on pain that prevents walking [2]

Management

Prognosis

  • Depends on how quickly the condition is diagnosed and treated
  • Delaying diagnosis and treatment could result in early-onset degenerative hip arthritis and hip reconstruction [5]
  • Prognosis also depends on whether condition is stable vs unstable
  • Unstable SCFE can have up to 50% chance of osteonecrosis
  • 0% chance of osteonecrosis in stable SCFE

Nonoperative

  • Hip Spica Cast Immobilization
  • Used only in prophylaxis to prevent SCFE in contralateral hip
  • Not recommended for treatment of involved hip

Operative

  • Surgical fixation with a central screw
  • Most accepted treatment
  • Low incidence of re-slippage, osteonecrosis, and chondrolysis
  • Bone graft Epiphysiodesis
  • Bone graft is harvested from the iliac crest and inserted across the growth plate
  • Re-slippage common
  • In situ-fixation with multiple pins
  • Risk of inadequate fixation and could damage vascular supply to epiphysis [2]

Rehab and Return to Play

Rehabilitation

Return to Play

Complications

See Also

References

  1. ↑ Weiner D. Pathogenesis of slipped capital femoral epiphysis: current concepts. Journal of Pediatric orthopedics. Part B. 1996 ;5(2):67-73.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Aronsson DD, Loder RT, Breur GJ, Weinstein SL. Slipped capital femoral epiphysis: current concepts. J Am Acad Orthop Surg. 2006;14(12):666-679
  3. ↑ 3.0 3.1 Loder RT, Skopelja EN. The epidemiology and demographics of slipped capital femoral epiphysis. ISRN Orthop. 2011;2011:486512.
  4. ↑ Witbreuk M, van Kemenade FJ, van der Sluijs JA, Jansma EP, Rotteveel J, van Royen BJ. Slipped capital femoral epiphysis and its association with endocrine, metabolic and chronic diseases: a systematic review of the literature. J Child Orthop. 2013;7(3):213-223.
  5. ↑ 5.0 5.1 5.2 Peck D. Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2010;82(3):258-262
  6. ↑ Gholve PA, Cameron DB, Millis MB. Slipped capital femoral epiphysis update. Curr Opin Pediatr. 2009;21(1):39-45
  7. ↑ Aprato A, Conti A, Bertolo F, Massè A. Slipped capital femoral epiphysis: current management strategies. Orthop Res Rev. 2019;11:47-54.
Created by:
John Kiel on 30 June 2019 19:55:47
Authors:
Last edited:
5 October 2022 13:11:08
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